Surgical correction for lower lid epiblepharon in Asians

A Comparison between 2-Octyl Cyanoacrylate and Conventional Suturing for the Closure of Epiblepharon Incision Wounds in Children: A Retrospective Case-Control Study

Background: Tissue adhesive has been widely used in ophthalmic surgery for various procedures, proving both effective and safe. However, no studies have compared the surgical efficacy of the tissue adhesive 2-octyl cyanoacrylate (SurgiSeal®) to that of traditional suture closure in Asian children undergoing surgery for lower lid epiblepharon. Methods: This is a single-center retrospective case-control study. Surgical correction for epiblepharon was performed on 22 patients from November 2019 to May 2023. A total of 20 patients who were followed up for at least 1 month were included for analysis. After standardized epiblepharon surgery, group A underwent wound closure with a subcuticular suture and 2-octyl cyanoacrylate, and group B underwent closure with a 6-O fast-absorbing surgical gut suture. Patients were followed up at 1, 4, and 12 weeks post-surgery. Results: A total of 10 patients (20 eyes) underwent skin closure with tissue adhesives (group A), and 10 patients (18 eyes) underwent wound closure using conventional suture material (group B). No significant differences in the sex ratio, mean age at operation, pre- and postoperative best-corrected visual acuity (BCVA), or average surgical time were observed between groups. Both groups exhibited improved postoperative BCVA, with symptom relief and a significant decrease in the severity of keratopathy after surgery. Neither recurrence nor complications were reported during follow-up. The aesthetic results were similar between groups, while caregivers of children in the tissue adhesive group expressed high satisfaction regarding the ease of postoperative care. Conclusions: Successful closure of lower lid epiblepharon surgery wounds in children can be performed using 2-octyl cyanoacrylate (SurgiSeal®). This method is simple, safe, and effective when compared to conventional sutures.

Reducing tension step by step in epicanthus and lower eyelid incision for treating cilial entropion in children: A case series analysis

OBJECTIVE

To evaluate the surgical outcomes of a modified technique for treating congenital cilial entropion in children, which involves reducing tension step by step in the epicanthus and lower eyelid incision.

METHODS

The observational group consisted of 153 pediatric patients (81 males and 72 females) who were treated using the modified technique, whereas the control group included 124 patients (68 males and 56 females) who were treated using the rotating suture surgery. All the participants were bilateral. Surgical outcomes were classified as good, fair, or poor, and the recurrence rate, scar condition, inferior eyelid position, and patient satisfaction were also assessed.

RESULTS

The mean follow-up period was 9.13 ± 3.50 months (range: 3-14 months) for the observational group and 6.93 ± 4.51 months (range: 3-14 months) for the control group. In the observational group, surgical success with "good" outcomes was achieved in 300 eyes (98.04%), compared to 224 eyes (90.32%) in the control group. No recurrence occurred in the observational group, whereas the recurrence rate in the control group was 4.43%. Postoperative scar formation was mild in the observational group. The average scar score was 1.27 ± 0.96 in the observational group and 2.70 ± 0.99 in the control group, with a statistically significant difference (P < 0.001). Neither overcorrection nor postoperative ectropion was observed in both groups.

CONCLUSION

The modified technique effectively corrected medial entropion and trichiasis in the lower eyelid, resulting in stable postoperative outcomes, mild scar formation, quick recovery, flexible eyelid motility, and stable ocular surface. Therefore, it can be widely applied to children with congenital entropion and trichiasis.

Rotating suture technique combined with lid margin split and lower eyelid retractor disinsertion for epiblepharon

Epiblepharon is an eyelid disease affecting 46-52.5% of Asian children. The Hotz procedure was commonly used for the treatment. However, the currently preferred technique is the rotating suture technique. This study aimed to report the recurrence rate and the complications of using the rotating suture technique combined with lid margin split and lower eyelid retractor (LER) disinsertion of epiblepharon. This was a retrospective study of the procedures performed between January 2017 and December 2020. This study included 64 eyelids of 37 patients who underwent the consecutive rotating suture technique, lid margin split, and LER disinsertion simultaneously for lower eyelid epiblepharon and were followed up for at least 6 months. The mean age of the patients who underwent surgery was 9.5 (5-28) years. The mean observation period was 8.3 (6-27) months. Recurrence was observed in one eyelid (1.6%). The complications included an ectopic eyelash on one eyelid (1.6%). LER disinsertion performed in this study had two advantages. First, the imbalance between the anterior and posterior lamellae was corrected. Disinserting the LER, the tarsal plate could be repositioned cranially, effectively addressing this imbalance. Second, LER disinsertion ensured direct exposure of the lower margin of the tarsal plate, facilitating the implementation of a reliable rotating suture. In conclusion, promising results were achieved by combining the rotating suture technique with LER disinsertion and lid margin splitting.

Orbicularis muscle fixation downward for the correction of congenital epiblepharon in Chinese patients

BACKGROUND

Congenital epiblepharon (CE) is a congenital eyelid deformity unique to young individuals of Asian descendants, and it might cause a sequence of other complications such as corneal damage and ocular foreign body sensation. Surgery is the most effective approach to treat this condition. Here, this study evaluated the effectiveness and safety of the orbicularis muscle fixation downward (OMFD) procedure for correcting CE.

METHODS

This study enrolled 29 patients who were diagnosed with CE. These patients experienced significant ocular irritation leading to epiphora and corneal injury and, therefore, they underwent the OMFD procedure that was performed by the same surgeon. The cases were divided into 3 grades according to postoperative outcomes.

RESULTS

The OMFD procedure was performed on 55 lower lids of the 29 patients. The average age of the patients was 9.6 years. The mean follow-up duration was 17 months. No perioperative complications were observed, and successful surgical outcomes were achieved in all 29 patients. No postoperative necrosis, infection, or corneal epithelial injury occurred. None of the patients exhibited significant scarring. Three patients showed residual 1-3 eyelashes touching the nasal corneal or bulbar conjunctiva at the inner canthus during the last postoperative examination. These patients did not undergo further surgery as there were no obvious irritation symptoms or corneal damage.

CONCLUSIONS

The fixation of the pretarsal orbicularis muscle is a simple and effective modification of the Hotz procedure to correct CE. The key aspect of this procedure is the suturing of the pretarsal orbicularis muscle and the lower eyelid retractors.

Subciliary Rotating Sutures Combined With Modified Hotz Procedure for Correction of Congenital Lower Eyelid Entropion

PURPOSE

Standard techniques for the treatment of congenital lower eyelid entropion may not yield suitable outcomes or may result in overcorrection if disinsertion of the lower eyelid retractors is not the primary cause. Herein, we propose and evaluate a technique using subciliary rotating sutures combined with a modified Hotz procedure for repair of lower eyelid congenital entropion that addresses these concerns.

METHODS

A retrospective chart review was conducted of all patients who underwent lower eyelid congenital entropion repair by a single surgeon using subciliary rotating sutures combined with a modified Hotz procedure between 2016 and 2020. Study variables included patient demographics, follow-up period, postoperative complications, operative success, and recurrence.

RESULTS

Twelve patients (19 eyelids) met the study inclusion criteria. The mean patient age was 7.1 ± 6.1 years (range, 0.2-22 years). Nine of the patients were female (75%) and 3 were male (25%). The distribution of eyelids was 8 right (42%) and 11 left (58%). The mean follow-up time was 19.5 ± 15 (range 2.5-45) months. There were two eyelids (11%) that had entropion recurrence after initial repair in patients with concomitant compound disease processes. Repeated repair resulted in success with no recurrence at last follow-up. Overall, the described entropion repair technique was successful and without recurrence in 17 eyelids (89%). There were no cases of ectropion, lid retraction, or other complications.

CONCLUSIONS

Subciliary rotating sutures combined with a modified Hotz procedure are effective for correction of congenital lower eyelid entropion. As the technique does not manipulate the posterior layer of the lower eyelid retractors, it may be useful for when retractor reinsertion does not yield adequate improvement and may also reduce the risk of eyelid retraction and overcorrection in particular cases.

Comparing the effectiveness of two surgical techniques for treating lower lid epiblepharon in children: a randomized controlled trial

A multicenter randomized controlled trial was conducted to compare the effectiveness of incisional and nonincisional surgical techniques for treating lower lid epiblepharon in children. The study included 89 eyes from 50 children aged 3-15 years (mean, 7.5 ± 2.4 years) with moderate lower lid epiblepharon. Patients were randomly assigned to either incisional (modified Hotz procedure with lid margin splitting; 45 eyes of 25 patients) or nonincisional (44 eyes of 25 patients) surgery groups. Treatment outcomes and changes in astigmatism were evaluated 6 months after surgery. Incisional surgery provided a significantly higher percentage (77.8%) of well-corrected treatment results (P = 0.026; odds ratio, 2.88; 95% confidence interval, 1.07-8.22) than nonincisional surgery (55.4%). The mean change in astigmatism 6 months after surgery was - 0.24 ± 0.42 and - 0.01 ± 0.47 D in the incisional and nonincisional surgery groups, respectively. The improvement in astigmatism was significantly higher in the incisional surgery group than in the nonincisional surgery group (P = 0.008). The incisional surgical treatment for moderate epiblepharon in children resulted in a higher number of well-corrected patients, indicating an absence of both ciliary touch and superficial keratitis as well as statistically significant improvements in astigmatism correction.

Minimal lower eyelid epicanthoplasty combined with thermal contraction to treat epiblepharon in chinese children

BACKGROUND

To evaluate the clinical efficacy of combined minimal lower eyelid epicanthoplasty and thermal contraction for epiblepharon repair in Chinese children.

METHODS

Between January 2017 and August 2020, a single surgeon corrected epiblepharon in Chinese children using minimal lower eyelid epicanthoplasty combined with thermal contraction. First, a minimal epicanthoplasty flap to balance the lower eyelid was made cross the lower eyelid epicanthus, which connected with a 20-mm-long incision 1.5 mm below the lower eyelid margin. After removing the hypertrophic orbicularis oculi muscle running between the lower epicanthal fold and the medial canthal tendon, thermal cauterization was applied to increase lower eyelid rotation by creating adhesions between the lower eyelid retractor and tarsus. The residual medial edge was sutured to the corner of the epicanthus to decrease the lower eyelid epicanthus. The postoperative follow-up ranged from 3 to 24 months. We retrospectively analyzed cases to determine whether this approach decreased the lower eyelid epicanthal fold to equalize the tension of the lower eyelid. The surgical outcomes including the direction of lower eyelid eyelashes, complications, and refractive errors were evaluated.

RESULTS

Data from each eye of 53 Chinese children (29 female, 24 males; mean age: 5.3 ± 2.3 years) who had undergone minimal lower eyelid epicanthoplasty combined with thermal contraction were included. During follow-up, recurrence was observed in just one of the 106 eyes (0.94%), and two eyes (1.89%) showed under-correction. No visible scars formed in the postoperative period. All patients' parents were satisfied with the cosmetic results and had no serious complaints. The mean astigmatism was significantly reduced by the surgery from 1.82 ± 0.45 diopters (D) preoperatively to 1.43 ± 0.36 D postoperatively (P < 0.05).

CONCLUSION

This surgery is easy to design, time-efficient, and is effective in the correction of epiblepharon. The procedure allows surgeons to achieve good appearance and natural eyelid contour without apparent complications.

Modified Epiblepharon Repair Preserving Orbicularis Oculi Muscle

Methods

A retrospective review of was conducted of patients who received modified epiblepharon repair preserving orbicularis oculi muscle from April 2016 to October 2018. Removal of the orbicularis oculi muscle was minimally performed with eyelash rotating sutures and epicanthal weakening procedure. The preoperative severity of epiblepharon was classified according to skin fold height and cilia-corneal touch. Main postoperative outcomes were evaluated by functional success and cosmetic satisfaction.

Results

A total of 208 eyelids of 104 patients were evaluated. The mean age was 7.2 ± 4.2 years with a mean follow-up time of 5.6 ± 4.6 months. Functional success was obtained in 206 eyelids (99.0%). Only two cases that had a total epiblepharon score of 7 showed a recurrence of mild cilia-corneal touch, but reoperation was not required. The cosmetic satisfaction score was 8.7 ± 1.8 (range, 1–10). The excellent cosmesis group with a cosmetic score of 9 or higher had significantly higher skin fold height (p=0.027).

Conclusions

Modified epiblepharon repair preserving orbicularis oculi muscle can be effective in the treatment of lower epiblepharon regardless of its severity. Excellent outcomes were obtained functionally and cosmetically without debulking of the orbicularis oculi muscle.

Skin redraping for correction of lower eyelid epiblepharon combined with medial epicanthal fold: a retrospective analysis of 286 Asian children

OBJECTIVE

This study was performed to evaluate the clinical effect of skin redraping on lower eyelid epiblepharon accompanied by a medial epicanthal fold.

METHODS

This retrospective case series involved 572 eyes of 286 patients who underwent skin redraping surgery to treat lower eyelid epiblepharon accompanied by a medial epicanthal fold from January 2015 to May 2019. The postoperative surgical results were classified as "good", "fair" and "poor". The incision scars were assessed using the Vancouver scar scale. The patients' subjective satisfaction and incidence of complications were also documented.

RESULTS

The mean patient age at the time of surgery was 6.9 ± 3.6 years (3-12 years), and the mean follow-up time was 32.6 ± 13.5 months (6-58 months). The clinical symptoms and severity of keratopathy were improved postoperatively. "Good" surgical outcomes were obtained in all patients, the mean Vancouver scar scale score was 1.1 ± 0.3, and hypertrophic scar formation did not occur. A total of 272 patients and their guardians were "very satisfied" with the cosmetic outcomes.

CONCLUSION

Skin redraping was effective and endurable in the treatment of lower eyelid epiblepharon accompanied by a medial epicanthal fold. The postoperative scars were slight and nearly invisible, and no cases of recurrence were observed in this study.

High-frequency radio wave electrocautery in modified Hotz operations for epiblepharon correction

To report the experience and advantageous effects of high-frequency radio wave electrocautery in modified Hotz operations for epiblepharon, We reviewed the records of all pediatric patients who underwent a modified Hotz operation with the use of high-frequency radio wave electrocautery (Ellman Surgitron Dual Frequency RF S5; Ellman International, Inc, Hewlett, NY) for epiblepharon between March 2016 and September 2019 at Korea University Guro Hospital. We evaluated the success rate, complications, recurrence rate and degree of satisfaction of our technique. Information from the medical records was collected, including demographics, ocular symptoms, severity of keratopathy, operation time, success/recurrence rate, and complications. 133 patients (98.52%) showed good correction of epiblepharon without complications or unpleasant cosmetic problems during 3 months of median follow-up period. Two patients (1.48%) showed recurrent corneociliary touch, but the degree was very mild and re-operation was not performed. One patient showed mild ectropion on his left lower eyelid, but the patient recovered well without operation. For complications, suture abscess and granulation were the most common, 3 cases in each, but all of those were temporary and resolved with conservative management. The approach with electrocautery for epiblepharon allows precise and fast incision of the lower eyelid, little bleeding, and minimal scarring. Surgical outcomes associated with the modified Hotz operation with electrocautery were consistent with previous studies.

Adjustable Medial Epicanthoplasty Using a Rotational Flap for Epiblepharon Repair

ABSTRACT

This report aimed to introduce the new adjustable rotational skin flap for epicanthoplasty in combination with traditional epiblepharon repair by the modified Hotz procedure. This retrospective study involved 25 consecutive patients with superficial punctate keratitis secondary to epiblepharon complicated with epicanthal fold who underwent the combined surgery between 2019 and 2020. The mean patient age was 11.4 years in this study with a median follow-up was 8 months (range, 3-12 months). The rationale of the surgery was to release vertical tension of the eyelids by dissecting dense connective tissue beneath the epicanthal fold and to form a new medial canthus using a rotational skin flap supplied by the redundant the upper and/or lower eyelid skin excised during the epiblepharon repair. Postsurgical resolution of superficial punctate keratitis and patient satisfaction was achieved in all patients. Additionally, there were no complications, and no revisional surgery was required in all patients for a median 8 months follow-up period. Utilizing a rotational skin flap during epiblepharon repair is a useful adjunct during epicanthoplasty surgery. This modification is well tolerated and allows for intraoperative adjustment, whereas minimizing scarring and allowing for improved tissue relaxation.

Acquired Epiblepharon Alleviated With Teprotumumab Treatment in Active Thyroid Eye Disease Patient

A 46-year-old Asian female patient with thyroid eye disease reported ocular irritation, eyelid swelling, diplopia, and pain with eye movement. The patient was diagnosed with active thyroid eye disease and secondary thyroid eye disease-acquired epiblepharon, which was causing bilateral punctate epithelial erosion. Treatment was started with newly U.S. Food and Drug Administration approved teprotumumab, an insulin-like growth factor-1 receptor inhibitor. Four infusion treatments later, the patient's epiblepharon was alleviated with minimal side effects. In this report, the authors present a case of thyroid eye disease-acquired epiblepharon resolving with teprotumumab treatment.

Surgical Correction of Lower Lid Epiblepharon With Skin-Only Resection Using a Novel Design

ABSTRACT

This study is to report the surgical outcome of lower lid epiblepharon repair with skin-only resection using a newly designed incision line. A retrospective, noncomparative, interventional case series analysis of 134 eyes of 67 patients, who underwent surgical correction of lower lid epiblepharon with skin-only resection using the new incision design, was performed. After marking the 4 vertical lines at the medial canthus, punctum, midpoint, and lateral canthus, the upper and lower incision lines were drawn from the medial canthus through punctum to the lateral canthus with novel design. After incising the skin along the marked line, gentle dissection of the skin flap from the underlying orbicularis muscle was performed. Only skin flap was excised and closed. The patients were followed up for more than 6 months. The mean age of patients was 7.9 ± 3.7 years (range 4-13 years) and the mean follow-up period was 18.0 ± 5.7 months (range 13-31 months). During the follow-up period, recurrence of the epiblepharon was not observed. There was no occurrence of complications such as lower lid ectropion or retraction. Skin-only resection using a newly designed incision line is a simple and effective method to fully correct the medial portion of the lower lid epiblepharon and prevent dog-ear formation or overcorrection at the lateral portion, and prominent lid crease.

Morphological changes after lower eyelid epiblepharon surgery in Asian children

Background

This study aimed to determine the morphological changes in Asian lower eyelid epiblepharon patients after surgery.

Methods

The medical records of 59 patients who underwent lower eyelid epiblepharon repair were reviewed retrospectively. Eighty-nine patients who underwent strabismus surgery were set as the control group. The photographs for each group were analyzed based on the following factors: inferior half area (IHA) of the eye, eyelash angular direction (EAD), angle between the eyelashes and the cornea, marginal reflex distance 1 (MRD₁) and marginal reflex distance 2 (MRD₂).

Results

After surgery, the medial EAD changed from 92.45° ± 20.21° (mean ± SD) to 79.43° ± 23.31°, while the central and lateral EADs were unchanged. IHA increased from 36.33 ± 9.78 mm³ to 43.06 ± 10.57 mm³, and MRD₁ increased from 1.92 ± 0.99 mm to 2.50 ± 0.93 mm, whereas MRD₂ did not change. The mean angle between the eyelashes and the cornea increased from 39.64° to 72.19° immediately postoperatively, but had reduced to 58.75° 3 months later, followed by no further significant change at the 6-month and 9-month postoperative follow-ups.

Conclusions

There is morphological changes of the eyelid after lower eyelid epiblepharon surgery, with increases in the IHA and MRD_1. In addition, contact between the eyelashes and the cornea occurred mainly in the medial portion of the eyelid the position, which everted and stabilized over 3 months. Thus, follow-up observations are required for at least 3 months to properly evaluate the surgical outcome.

Comparison of ocular axis and corneal diameter between entropion and non-entropion eyes in children with congenital glaucoma

BACKGROUND

Children with congenital glaucoma are often accompanied by acquired epiblepharon in the lower eyelid, which causes entropion of the lower eyelid and damages the cornea.

AIM

To infer the possible causes of lower eyelid entropion by comparing the difference of ocular axis and corneal diameter between inverted and non-inverted ciliary eyes in children with congenital glaucoma.

METHODS

A total of 15 patients (11 males and 4 females) diagnosed with congenital glaucoma between July 2016 and January 2019 at Tongren Hospital were included. Five patients had bilateral glaucoma, and ten had unilateral glaucoma. Each patient had only one eye with lower eyelid entropion which is associated with congenital glaucoma. All the patients had no entropion in another eye. The clinical data were collected. Main outcome measures were the ocular axis and corneal diameter.

RESULTS

The average age of the 15 patients was 1.85 ± 0.49 years. Paired t-test showed that the average ocular axis of congenital glaucoma eyes with lower eyelid entropion (24.86 ± 3.44 mm) was significantly longer than that of congenital glaucoma eyes without lower eyelid entropion (20.79 ± 1.34 mm; P < 0.001). The average corneal diameter of congenital glaucoma eyes with lower eyelid entropion (13.61 ± 0.88 mm) was also significantly greater than that of congenital glaucoma eyes without lower eyelid entropion (11.63 ± 0.48; P < 0.001).

CONCLUSION

The rapid growth of the ocular axis and corneal diameter may be the main cause of congenital glaucoma with acquired lower eyelid entropion. Therefore, children with poor control of intraocular pressure and excessive growth of ocular axis and corneal diameter must be observed for the existence of acquired epiblepharon.

Gene expression profiles of pro-inflammatory mediators in the conjunctiva of patients with epiblepharon

PURPOSE

To investigate the gene expression of pro-inflammatory mediators in the conjunctiva of pediatric patients with epiblepharon in a case-control study.

METHODS

Twenty healthy controls and 15 pediatric patients with epiblepharon were enrolled from April 23, 2020 to June 15, 2020. Epiblepharon severity was divided into class I-III (least to moderate severity) and class IV (most severe). We obtained impression cytologic specimens from the medial palpebral conjunctiva of the participants to measure the gene expression of interleukin (IL)-1β, IL-6, matrix metalloproteinase 9 (MMP9), and mucin 5AC (MUC5AC) using quantitative reverse transcription polymerase chain reaction.

RESULTS

The mean age in the epiblepharon group was 9 years (range 7.5-11 years), and that in the healthy control group was 9.5 years (range 8-11.3 years). IL-1β, IL-6, and MMP9 expression levels were 2.08 (p < 0.05), 2.11 (p < 0.05), and 2.48 (p < 0.05) fold higher, respectively, in the epiblepharon group than in the healthy control group. However, MUC5AC gene expression was not different between healthy subjects and patients with epiblepharon. IL-1β, IL-6, and MMP9 expression levels in class IV patients were 1.32 (p < 0.05), 1.77 (p < 0.05), and 1.98 (p < 0.05) fold higher, respectively, than in class I-III patients.

CONCLUSION

Epiblepharon may induce chronic inflammatory changes in the conjunctiva in addition to corneal epithelial damage. Therefore, early corrective surgery should be considered to prevent conjunctival inflammation.

Cause analysis and reoperation effect of failure and recurrence after epiblepharon correction in children

BACKGROUND

In children, it is common to see failure and recurrence in the correction of epiblepharon and to have reoperation due to obvious irritation symptoms and corneal injury.

AIM

To explore the causes of failure and recurrence after epiblepharon correction in children, to remove accurately redundant epiblepharon and orbicularis oculi muscle in patients via the cilia-everting suture technique combined with lid margin splitting in some patients due to inverted lashes in the medial part of the eyelid, and to observe the therapeutic effect.

METHODS

From 2015 to 2019, in the Outpatient Department of Ophthalmology of Beijing Tongren Hospital, 22 children (40 eyes) with epiblepharon, aged 5-12 years, were treated due to correction failure and recurrence. Fourteen patients (28 eyes) underwent the full-thickness everting suture technique, and eight patients (16 eyes) underwent incisional surgery. They were treated by reviewing the previous surgical methods and observing epiblepharon, eyelash direction, and corneal injury. During reoperation, a subciliary incision was made 1 mm below the inferior lash line. Incisional surgery for the lower eyelid was used to remove accurately redundant epiblepharon and part of the pretarsal orbicularis muscle. Subcutaneous tissue and the orbicularis muscle of the upper skin-muscle flap were anchored to the anterior fascia of the tarsal plate by rotational sutures. Lid margin splitting was used only for patients who had seriously inverted lashes located in the medial part of the eyelid. All patients were followed for 6-12 mo after reoperation to observe the lower eyelid position, skin incision, eyelash direction, corneal damage, and recurrence.

RESULTS

After reoperation, all the patients were corrected. Photophobia, rubbing the eye, winking, and tearing disappeared. There was no lower eyelid entropion, ectropion, or retraction. There was no obvious sunken scar or lower eyelid crease. The eyelashes were far away from the cornea, and when the patients looked down, the eyelashes on the lower eyelid did not contact the cornea or conjunctiva. The corneal injuries were repaired. Follow-up observation for 6 mo showed no recurrence of epiblepharon.

CONCLUSION

The type of suture method, the failure to remove accurately redundant skin and orbicularis muscle, the lack of cilia rotational suture use, and excessive reverse growth of eyelashes are the main causes of failure and recurrence after epiblepharon correction in children.

The Effect of Intraoperative Magnesium Sulphate Infusion on Emergence Agitation after Ambulatory Ophthalmic Surgery in Children

This study investigated whether intraoperative infusion of magnesium sulphate reduces the incidence of emergence agitation (EA) in paediatric patients who undergo ambulatory ophthalmic surgery using the Paediatric Anaesthesia Emergence Delirium (PAED) scale. Ninety-two paediatric patients who were scheduled for elective ophthalmic surgery were randomly allocated to two groups: control or magnesium. In the magnesium group, patients received an initial intravenous loading dose of 30 mg/kg of 10% solution of magnesium sulphate over 10 min and then a continuous infusion of 10 mg/kg×h during the surgery. In the control group, an equal volume of 0.9% isotonic saline was administered in the same way as in the magnesium group. The PAED scale was assessed at 15-min intervals until the PAED score reached below 10 at the postanaesthetic care unit. EA was defined as a PAED score of 10 or higher. Of the 86 patients recruited, 44 and 42 were allocated to the control and magnesium groups, respectively. The incidence of EA was 77.3% in the control group and 57.1% in the magnesium group (odds ratio, 0.392; 95% confidence interval, 0.154 to 0.997; p = 0.046). The intraoperative infusion of magnesium sulphate significantly reduced the incidence of EA.

Effect of Congenital Lower Eyelid Epiblepharon Surgery on Asymmetric Margin Reflex Distance 1

Objectives: To investigate the characteristics of margin reflex distance 1 (MRD1) asymmetry in congenital lower eyelid epiblepharon and its resolution after surgical correction of epiblepharon.Methods: Among patients who underwent lower eyelid epiblepharon surgery from November 2015 to September 2017, patients with a preoperative MRD1 difference of more than 1.0 mm between the two eyes according to medical photographs were defined as having MRD1 asymmetry. A postoperative MRD1 difference of less than 1.0 mm between the two eyes was regarded as MRD1 asymmetry resolution. The preoperative MRD1 difference was compared between subgroups with resolved or sustained MRD1 asymmetry. Astigmatism and amblyopia were also assessed.Results: Among 432 patients, MRD1 asymmetry was observed in 24 patients (5.6%). MRD1 was always lower in the side with more extensive epiblepharon. At 6 months after surgery, the mean MRD1 difference between the two eyes was significantly decreased (1.8 ± 0.7 mm to 0.5 ± 0.8 mm, p < .001, paired t-test) and MRD1 asymmetry resolution occurred in 19 patients (79%). In the resolved MRD1 asymmetry group, the preoperative MRD1 difference was 2.0 mm or less and was significantly smaller than that in the sustained MRD1 asymmetry group (p = .010, Mann-Whitney U test). Six patients had preoperative aniso-astigmatism ≥ 1.50 D. Unilateral amblyopia presented in nine patients (38%) and improved within 1 year postoperatively.Conclusions: MRD1 asymmetry can be resolved after epiblepharon surgery, especially when the preoperative MRD1 difference is 2.0 mm or less. Unilateral amblyopia was frequent, but the treatment outcome was good.

Reduction in Recurrence Rate by Combining Modified Hotz Procedure With Epicanthoplasty to Treat Congenital Epiblepharon

AIM

To determine whether patients with congenital lower lid epiblepharon treated with a modified Hotz procedure combined with epicanthoplasty have a decreased recurrence rate.

PATIENTS AND METHODS

Patients with epiblepharon of the lower eyelid corrected using a modified Hotz method between 2007 and 2017 were evaluated retrospectively by chart review to determine rates of complications and recurrence as well as whether the Hotz method was combined with epicanthoplasty. The recurrence rates for patients treated with the Hotz method alone or in combination with epicanthoplasty were compared.

RESULTS

A total of 60 patients (mean age, 13.6 years) and 115 eyelids were evaluated. All patients showed improvement in their symptoms and had no complications. Across the entire group, the recurrence rate for entropion was 23.5% (27 eyes). A modified Hotz procedure combined with epicanthoplasty was performed on 43 (37.4%) eyes. The recurrence rate for the group treated with a modified Hotz procedure combined with epicanthoplasty was significantly lower than that for patients who underwent the Hotz procedure alone (7.0% vs 33.3% P = 0.0012). There was no relationship between epicanthus severity and recurrence rate (P = 0.345).

CONCLUSION

In this study, we showed that patients who underwent a modified Hotz procedure combined with epicanthoplasty had a decreased recurrence rate. This improved outcome could be due to the simpler approach to the nasal side of the lower eyelid in epicanthoplasty, and epicanthoplasty can facilitate detachment of the upper eyelid from the lower eyelid.

Analysis of corneal real astigmatism and high order aberration changes that cause visual disturbances after lower eyelid epiblepharon repair surgery

This retrospective, cross-sectional study investigated changes in corneal low and high order aberrations (LOAs and HOAs) after lower eyelid epiblepharon repair surgery. In total, 108 eyes from 54 patients were evaluated. Wavefront analyses for calibrated LOAs and HOAs were performed using a Galilei G4 Dual Scheimpflug Analyzer before surgery and during the first and second follow-ups (f/u), adjusting for several risk factors. Flat keratometry (K) and axis values decreased significantly from baseline at the first f/u. At the second f/u, mean K and axis values decreased. Coma and trefoil increased from baseline at the first f/u and normalized by the second f/u. Spherical aberrations (SA) only decreased at the second f/u. After correction for risk factors, cylinder, coma, trefoil, and SA significantly increased at the first f/u; axis and flat K values decreased. At the second f/u, cylinder increased while axis and mean K values significantly decreased. Epiblepharon repair surgery may result in a shift from 'with-the-rule' to 'against-the-rule' axis change. Flat K, coma, and trefoil may be affected by mechanical force changes immediately post-surgery, while mean K values and SA may also change with corneal state changes including corneal erosion healing after the second f/u during the postoperative period.

A genome-wide significant association on chromosome 15 for congenital entropion in Swiss White Alpine sheep

Entropion is a known congenital disorder in sheep presumed to be heritable but no causative genetic variant has been reported. Affected lambs show a variable inward rolling of the lower eyelids leading to blindness in severe cases. In Switzerland, the Swiss White Alpine (SWA) breed showed a significantly higher prevalence for entropion than other breeds. A GWAS using 150 SWA sheep (90 affected lambs and 60 controls), based on 600k SNP data, revealed a genome-wide significant signal on chromosome 15. The 0.2 Mb associated region contains functional candidate genes, SMTNL1 and CTNND1. Pathogenic variants in human CTNND1 cause blepharocheilodontic syndrome 2, a rare disorder including eyelid anomalies, and SMTNL1 regulates contraction and relaxation of skeletal and smooth muscle. WGS of a single entropion-affected lamb revealed two private missense variants in SMTNL1 and CTNND1. Subsequent genotyping of both variants in 231 phenotyped SWA sheep was performed. The SMTNL1 variant p.(Asp452Asn) affects an evolutionary conserved residue within an important domain and represents a rare allele, which occurred also in controls. The p.(Glu943Lys) variant in CTNND1 represents a common variant unlikely to cause entropion as the mutant allele occurred more frequently in non-affected sheep. Therefore, we propose that these protein-changing variants are unlikely to explain the phenotype. Additionally, WGS of three further disconcordant pairs of full siblings was carried out but revealed no obvious causative variant. Finally, we conclude that entropion represents a more complex disease caused by different non-coding regulatory variants.

Modified Hotz procedure with CO2 laser ablation of the orbicularis oculi muscle for epiblepharon

OBJECTIVE

To introduce the use of a CO₂ laser for ablation of the orbicularis oculi muscle (OOM) in a modified Hotz procedure for correction of epiblepharon and to report its clinical outcome.

METHODS

A retrospective consecutive study was conducted from August 2014 to January 2018. Patients who had undergone surgical correction for epiblepharon with the modified Hotz procedure and a CO₂ laser ablation of OOM were included. The procedure includes a transverse subciliary incision with removal of a very small amount of skin using CO₂ laser ablation. The ablation was carried out continuously on parts of the pretarsal portion and parts of the preseptal portion of the OOM inferior to the lower edge of the incised skin. Finally, the incised skin was closed and secured to the tarsus. The patients were followed for direct inspection of the wound, the direction of the lashes, and the status of the cornea.

RESULTS

One hundred eyelids from 50 patients were enrolled. The average age was 6.4 years. The mean postoperative follow-up period was 14.3 months. In 90 eyelids (90.0%), the eyelashes were successfully outwardly everted. Undercorrections were noted in 10 eyelids (10.0%). To date, the cosmetic outcome was satisfactory in all cases without complications such as wound dehiscence, ectropion, and eyelid retraction.

CONCLUSIONS

A CO₂ laser is a safe and effective alternative to the scalpel in the modified Hotz procedure to correct epiblepharon. Its advantages include limited skin excision, minimal bleeding during surgery, short operation time, and a satisfactory clinical outcome.

A Novel Plastic Surgical Technique for Treating Congenital Entropion in Asians

Congenital entropion is an ocular condition involving malpositioning of the eyelid, which can result in ocular pain, conjunctival epiphora, or photophobia. Noninvasive treatment is effective in some cases; however, surgical treatment is indicated when keratitis and ocular irritating symptoms occur. There is no consensus regarding the most appropriate surgical technique. Moreover, some patients complain of changes in their appearance or unwanted incision scars after surgery. In particular, individuals with certain types of Asian heritage exhibit a lower eyelid morphology that differs from that of white individuals, caused by orbital fat locational difference. Subciliary muscle bulges cause swelling in the lower eyelid called Namidabuluro and are considered to create a youthful and beautiful appearance in Asians. Accordingly, some Asian individuals tend to be sensitive about changes to the appearance of the lower eyelid. To our knowledge, no report has yet described changes to Namidabukuro during congenital entropion repair in Asians. We describe a novel surgical technique for congenital entropion repair with the creation of cosmetically natural Namidabuluro in an East Asian cohort. The study included 8 lower eyelids of 4 Japanese female patients. Scarring was not noticeable in any of the 4 cases. Eversion of the cilia and the creation of cosmetically natural Namidabuluro were accomplished in all cases. There has been no case of recurrence yet. The novel surgical technique we developed enables not only the treatment of congenital entropion but also the creation of cosmetically acceptable Namidabuluro, resulting in increased patient satisfaction.

Epiblepharon correction in Korean children based on the epicanthal pathology

PURPOSE

This study aims to investigate the surgical outcomes of a novel epiblepharon correction method based on the pathologic features of epicanthal tissue. The correlation between the pathology and clinical presentations was also studied.

METHODS

This retrospective study included 72 eyelids of 36 children with epiblepharon and epicanthal folds. From July 2013 to March 2016, epicanthal tension-releasing procedure of subdermal fibrinolysis with orbicularis oculi ring myotomy were performed in 36 children. Photographs before and after operation were analyzed with Image J program. A clinical severity of the epiblepharon was scored based on the lower eyelid skin fold height (mild to severe). Subdermal fibrosis index was defined as the portion of fibrosis in low power field (× 40) and eyelid contour was assessed with custom software (MATLAB). Eighty eyelids without eyelid pathology were analyzed to establish the normal eyelid contour. The epicanthal tissues were classified into three categories: mild, moderate, and severe fibrosis.

RESULTS

The mean age of the patients was 5.5 years. Intercanthal distance (ICD) ratio was defined as Inner ICD (IICD)/outer ICD (OICD). The IICD/OICD was 0.41 in the severe epiblepharon group that is significantly longer compared to that of the mild epiblepharon group (0.38). Subdermal fibrosis index was higher in severe epiblepharon group. Eyelid contour was normalized and the cilia touch was resolved after the epicanthal tension-releasing procedure.

CONCLUSION

Epicanthal tension-releasing procedure with orbicularis oculi ring myotomy achieved favorable surgical outcomes. Clinical correlations with pathologic findings and satisfactory results of the procedure suggest that medial epicanthal fibrosis is the main pathologic feature causing epiblepharon and epicanthal folds.

Lower eyelid tension balance reconstruction: A new procedure for the repair of congenital epiblepharon with epicanthus

BACKGROUND

Congenital epiblepharon with epicanthus (CEE) is a common eyelid malposition in Asian children, which generally involves the lower eyelid. The induced cilial entropion may cause constant ocular irritation that requires surgical repair. The purpose of this study is to report the outcomes and surgical details of a novel procedure, lower eyelid tension balance reconstruction (LETBR), for the correction of CEE.

METHODS

Patients diagnosed with CEE underwent LETBR, which consists of modified half Z epicanthoplasty, and fixation between marginal orbicularis oculi muscle and lower eyelid retractor was reviewed retrospectively. The outcomes were classified as 'good' with no cilia-ocular surface contact, 'fair' with 5 or fewer asymptomatic cilia-ocular surface points of contact and 'poor' with most of the eyelashes remaining in contact with the eyeball. The surgical outcomes (good, fair or poor), recurrence and complications were evaluated.

RESULTS

One hundred and forty-nine eyelids of 78 patients (43 females and 35 males; mean age 6.6 ± 2.4 years, range 4-17 years) were evaluated in this study. The mean follow-up time was 14 months (range 9-24 months). At the last follow-up time, 144 of 149 eyelids were judged as 'good' (96.6%), the other 5 eyelids were judged as 'fair' (3.4%) and no eyelid was assessed with a 'poor' outcome. There were no significant complications or complaints about scarring on eyelids from patients or their parents.

CONCLUSION

LETBR is effective, safe and stable for patients with CEE.

Modified everting sutures: an alternative treatment for mild to moderate epiblepharon

PURPOSE

To describe a modified everting suture procedure which can be used in patients with mild to moderate epiblepharon who are undergoing general anaesthesia for surgical correction of coexisting ophthalmic conditions.

METHODS

A prospective, interventional, non-comparative case series on patients with mild to moderate epiblepharon who underwent the modified everting suture procedure using permanent nylon sutures while under general anaesthesia for other ophthalmic surgery, from May 2014 to May 2016, in a single tertiary institution. Main outcome measures were correction of epiblepharon, recurrence rate and complications.

RESULTS

There were a total of 29 patients. Mean age was 5.7±4.1 years (range 1.5-20 years). Twenty (69.0%) were male, 31.0% were female. All had concomitant surgery under general anaesthesia for levator resection (75.9%), frontalis sling (17.2%), strabismus surgery (3.4%) and coloboma correction (3.4%). Mean follow-up was 18.1±9.1 months. All patients were well corrected at 1 and 6 months postoperative follow-up. At 1 year after surgery, 28 (96.6%) were well corrected while one patient (3.4%) was undercorrected. At last follow-up, the overall recurrence rate was 6.9%, with a mean time from surgery to recurrence of 20.5 months. There were no complications encountered.

CONCLUSIONS

The modified everting suture procedure is a safe, effective, quick and relatively easy procedure for selected patients with mild to moderate epiblepharon, who are undergoing general anaesthesia for surgical correction of their coexisting ophthalmic conditions.

Non-incisional eyelid everting suture technique for treating lower lid epiblepharon

Background

This study investigated surgical outcomes of full-thickness eyelid everting sutures for lower lid epiblepharon and influential factors leading to surgical failure.

Methods

A retrospective review was conducted of patients with lower lid epiblepharon who underwent surgical correction using the full-thickness eyelid everting suture technique. Lower lid epiblepharon was assessed preoperatively using a morphological classification (class I–IV) according to the horizontal skin fold height and a functional classification (grade 0–3) according to the severity of keratopathy. Four stitches with 5-0 coated polyglactin 910 sutures per eyelid were made, and all procedures were conducted under local anaesthesia in an office-based setting. To assess surgical outcomes, we evaluated undercorrection at 1 month and surgical failure at 6 months after the procedure. Several factors affecting surgical failure were also investigated

Results

Sixty-eight eyes of 41 patients were included. There were no eyes showing an undercorrection at 1 month. Keratopathy was significantly improved at 6 months postoperation (P<0.01). All patients showed good cosmesis without undesired creation of a lower lid crease and no significant complications. Sixty-one eyes (89.7%) showed surgical success. Three patients (7.3%) required additional incisional surgery due to recurring irritation. The rate of surgical failure was significantly different between the patient groups classified by preoperative severity of keratopathy (P=0.026) and lower lid horizontal skin fold height (P<0.001). Multiple logistic regression analysis revealed that the lower lid horizontal skin fold height was significantly correlated with surgical failure (OR 18.367, P=0.002).

Conclusion

Non-incisional eyelid everting sutures have utility for the correction of lower lid epiblepharon with advantages including its simplicity, being performed in office under local anaesthesia and minimal changes in appearance. We suggest mild to moderate epiblepharon with class I or II horizontal skin fold height and grade 1 or 2 keratopathy as the criteria for considering this suture procedure.

Relationship between lower eyelid epiblepharon and epicanthus in Korean children

PURPOSE

This study aimed to determine the relationship between lower eyelid epiblepharon and epicanthus in Korean children.

METHODS

We performed a retrospective review of the medical records and preoperative photographs of 119 patients. These patients were aged 18 years or younger who underwent lower lid epiblepharon repair from January 2010 to December 2012. We also included 119 age- and sex-matched controls.

RESULTS

The mean age of the patients was 5.7 years (range: 2-16 years) in both groups. The presence of an epicanthal fold was common in each group (98.3%). The inner intercanthal distance/interpupillary distance (IICD/IPD) ratio was significantly greater in the epiblepharon group than in the control group (mean: 0.70 vs 0.67, p<0.001), especially in those aged 5 years or older. The IICD/outer intercanthal distance ratio was also greater in the epiblepharon group than in the control group (mean: 0.48 vs 0.46, p<0.001). The IICD/IPD ratio decreased with growth in the control group, but it did not decrease with growth in the epiblepharon group. The configuration of the epicanthus, in which the upper skin fold formed a confluent fold with the lower eyelid, had a higher prevalence in the epiblepharon group than in the control group (p = 0.001), especially in those aged 5 years or older.

CONCLUSION

In early childhood (<5 years), the relationship between epicanthus and epiblepharon cannot be established because of the high prevalence of epicanthus in children with or without epiblepharon. In children aged ≥5 years, persistent epicanthus was related to severe epiblepharon formation requiring corrective surgery.

Epiblepharon in congenital glaucoma: case-control study

BACKGROUND/AIMS

To assess the prevalence, clinical features and risk factors of lower lid epiblepharon among patients with congenital glaucoma.

METHODS

Cross-sectional, observational, case-control study. Patients diagnosed with congenital glaucoma between August 1999 and November 2014 were included. Demographic and clinical characteristic data were collected. Age-matched normal controls were recruited form general population. Main outcome measures were the prevalence, laterality and factors associated with epiblepharon in patients with congenital glaucoma.

RESULTS

The prevalence of lower lid epiblepharon was higher in patients with congenital glaucoma compared with control group (40.7% vs 13.3%, p<0.001). Unilateral epiblepharon was only shown in patients with congenital glaucoma (47.8% vs 0.0%, p<0.001). Multivariate analysis revealed that high intraocular pressure (IOP) at glaucoma diagnosis (OR=1.122), presence of corneal erosion (OR=82.664) and presence of buphthalmos (OR=12.600) were significantly associated with the presence of lower lid epiblepharon. In addition, unilateral epiblepharon was associated with unilateral buphthalmos and unilateral glaucoma (OR of 49.849 and 7.338, respectively).

CONCLUSIONS

The prevalence of epiblepharon was higher in patients with congenital glaucoma compared with age-matched general population. In patients with congenital glaucoma, epiblepharon was associated with corneal erosions. In addition, buphthalmos and initial high IOP were associated with the development of lower lid epiblepharon. More importantly, unilateral buphthalmos was also significantly associated with unilateral epiblepharon. Therefore, in patients with congenital glaucoma, presence of epiblepharon should be evaluated especially in patients accompanying buphthalmos or corneal erosion.

Modified Hotz Procedure Combined With Modified Z-Epicanthoplasty Versus Modified Hotz Procedure Alone for Epiblepharon Repair

PURPOSE

To compare the outcomes of the modified Hotz procedure alone and combined with modified Z-epicanthoplasty for correction of epiblepharon.

METHODS

Seventy-one Chinese patients who underwent epiblepharon repair were divided into 2 groups. In group 1, 33 patients (59 eyes) were operated on with the modified Hotz procedure. In group 2, 38 patients (71 eyes) were operated on with the modified Hotz procedure combined with modified Z-epicanthoplasty. Treatment outcomes were classified as "excellent" with no cilium-ocular surface touching, "fair" with 5 or fewer cilia-ocular surface touchings, and "poor" with more than 5 cilia-ocular surface touchings. Incision scars were evaluated by the Vancouver scar scale (VSS).

RESULTS

There were no significant differences in the age or sex distribution between the two groups. For group 1, the outcome was excellent for 46 eyes (78%) and fair or poor for 13 eyes (22%). For group 2, the outcome was excellent for 70 eyes (98.6%) and fair for only 1 eye (1.4%). Thus, group 2 had significantly more excellent outcomes compared with group 1 (p < 0.001). The Vancouver scar scale of the lower eyelids in group 1 was 1.10 ± 0.30 and 1.04 ± 0.20 in group 2 after correcting for the follow-up period (p = 0.292). The medial canthus Vancouver scar scale in group 2 was 1.13 ± 0.37, which was not different from the lower eyelid Vancouver scar scale (p = 0.471).

CONCLUSIONS

The modified Hotz procedure combined with modified Z-epicanthoplasty is more effective in correcting lower eyelid epiblepharon than the modified Hotz procedure alone. The combined procedure does not produce obvious lower eyelid or medial canthus scars.

Conservative Management of Lower Eyelid Epiblepharon in Children

PURPOSE

Although much literature has focused on various techniques to repair epiblepharon, no study has addressed how frequently surgical intervention is required.

METHODS

The authors tabulated data from all patients with epiblepharon seen over the past 15 years.

RESULTS

Eighty-nine patients were included, 61 (69%) with tearing, discharge, conjunctival injection, or eye rubbing. Trichiasis was present in 15 cases (17%), 6 (7%) with corneal staining. In all cases, the initial treatment was conservative: antibiotic ointment or tear substitutes in 73 cases with trichiasis, symptoms of irritation, or corneal changes and observation in the remaining 16 cases. Three children (3%) were referred for eyelid surgery because of persistent symptoms. No patient had corneal scarring or long-term complications.

CONCLUSIONS

Although vision-threatening complications can result, a trial of topical antibiotic ointment and/or ocular lubricants was effective in nearly all patients. Most resolved with minimal symptoms. The few eventually requiring eyelid surgery suffered no long-term complications. The authors recommend a trial of conservative treatment before eyelid surgery is undertaken. [J Pediatr Ophthalmol Strabismus. 2017;54(1):15-16.].

Management of epiblepharon: state of the art

PURPOSE OF REVIEW

Epiblepharon is prevalent in East-Asian children. As the population in Asia is increasing, so is the demand for epiblepharon surgery. Surgeons should be familiar with the standards of beauty and needs of Asian people for epiblepharon management. This review provides a comprehensive summary of the published studies on the clinical manifestations, pathophysiology, and management of epiblepharon.

RECENT FINDINGS

Astigmatism is prevalent in epiblepharon patients, which can contribute to amblyopia. Early surgery and visual rehabilitation is important for epiblepharon patients with a high degree of astigmatism and amblyopia. Various etiologic factors play a role in the pathophysiology of epiblepharon. Surgical procedures focusing on creation of a lower eyelid crease have been popular for treating epiblepharon in Western textbooks; however, this is not appropriate for Asian patients in whom, a crease may be undesirable. In selecting surgical methods, it is important to resect a minimal amount of skin-muscle to avoid the adverse effects of ectropion and eyelid retraction.

SUMMARY

Although epiblepharon may resolve with facial growth, surgical correction is needed for cases in which there is significant corneal injury from the lash touch. Surgical management should focus on techniques that are effective, with little chance of complication, and do not create a lower eyelid crease.

Epiblepharon in Chinese children: relationships with body mass index and surgical treatment

PURPOSE

To evaluate the relationship between the incidence of lower eyelid epiblepharon and body mass index in Chinese children and report the outcomes of a rotating suture technique or the L-plasty procedure aimed at correcting the structural anomalies.

METHODS

The medical records of patients treated surgically, with either rotating suture procedure or L-plasty, for lower eyelid epiblepharon were reviewed retrospectively and compared with an age-matched control group of children without epiblepharon. Body mass index (BMI) was calculated as weight in kilograms divided by the square of height in meters.

RESULTS

A total of 67 patients (mean age, 5.7 ± 2.6 years) and 178 controls were included. All patients had coexistent epicanthus. In 62 patients, rotating suture procedures were used; in 5, L-plasty. The BMI in 4- to 6-year-old boys with epiblepharon was significantly higher than that in children without epiblepharon (P = 0 .042). All patients showed successful surgical outcomes according to improvement of symptoms and lack of cilia-cornea contact. There were no cases of recurrence or other complications.

CONCLUSIONS

Obesity may be an aggravating factor in cases of lower eyelid epiblepharon, which may be corrected effectively with the rotating suture procedure and the L-plasty procedure. The L-plasty procedure is recommended for patients with coexistent severe epicanthus.

Is it truly necessary to add epicanthoplasty for correction of the epiblepharon?

BACKGROUND

There are many modified variations of the original Hotz procedure for the repair of the epiblepharon. No matter which procedure is used, there must be some factors that may cause recurrence. One of possible causes of these unsatisfactory results can be due to the presence of epicanthal folds (EFs) among the oriental population. It is important to determine whether patients should be repaired with the simple epiblepharon or if it should be combined with epicanthoplasty especially for actively growing children.

METHODS

All the patients were between 4 and 7 years old and had both epiblepharon and EF. The EFs were classified in 3 types, and all patients were operated on with the modified Hotz procedure. A "good" outcome was defined to be no contact between the eyelash and eyeball, and a "fair" outcome was defined to be several eyelashes contact with the eyeball, without any annoying symptoms. A "poor" outcome was defined to be most of the eyelids still in contact with the eyeball, and these patients persistently complain of irritation or keratitis.

RESULTS

The study included 46 lower eyelids of 23 patients (14 females, 9 males; mean age, 5.7 years) who underwent operation. Thirty-five eyelids (76.1%) were assessed to have a "good" outcome, 9 eyelids (19.6%) were assessed to have a "fair" outcome, and 2 eyelids (4.3%) were assessed to have a "poor" outcome.

CONCLUSIONS

We firmly believe that epicanthoplasty is not necessarily performed routinely for all epiblepharon unless there is any specific reason to justify the combined procedure.

A Review of Eyelid Margin Malpositions: A Unique Spectrum in a South-East Asian Tertiary Hospital

PURPOSE

Due to the anatomical differences between the Asian and non-Asian eyelid, the authors hypothesize a different spectrum of eyelid margin malposition conditions seen in Singapore as compared with a predominant Caucasian population. The purpose of the study is to describe the spectrum of eyelid margin malpositions that were operated in a South-East Asian Tertiary Hospital.

METHODS

Retrospective study involving all patients who required surgery for eyelid margin malpositions over a 2-year period. The etiology and ethnic spread of patients were analyzed for each eyelid margin malposition.

RESULTS

A total of 249 eyelids (144 patients) were analyzed. There were 127 Chinese (88.2%), 8 Malays (5.6%), 6 Indians (4.2%), 2 Indonesians (1.4%), and 1 Korean (0.7%). Epiblepharon (53.4%) was the commonest surgery performed, followed by entropion (25.7%) and ectropion (20.9%). Among patients with epiblepharon and entropion, Chinese patients formed the overwhelming majority (>95%). There were no Eurasians or Indians who presented with epiblepharon or entropion. Among patients with ectropion, there was a higher representation of Indian patients (16.7%).

CONCLUSIONS

This study shows that the spectrum of eyelid margin malpositions in Singapore is unique and that developmental epiblepharon remains the commonest eyelid margin malposition requiring surgery. In terms of involutional eyelid margin malpositions, entropion is more common than ectropion, especially among the Chinese. The similarity in terms of eyelid involvement and ethnic distribution of both epiblepharon and involutional entropion suggests that there is a common factor in both these conditions, which the authors infer is due to the unique anatomy of the Asian eyelid.

The clinical characteristics and surgical outcomes of epiblepharon in korean children: a 9-year experience

Purpose. To examine the demographic characteristics, clinical features, surgical outcomes, and long-term prognoses of epiblepharon in Korean children. Methods. Epiblepharon patients who were followed for ≥ 6 month following surgical correction between January 2005 and December 2013. The patient demographics, clinical features, concomitant disorders, surgical outcomes, and complications were retrospectively reviewed. Results. A total of 768 epiblepharon records were included in the analysis. The mean patient age was 6.55 ± 2.37 years. At presentation, 712 patients (92.8%) complained of typical epiblepharon symptoms. The mean patient age at surgery was 6.95 ± 2.52 years, with 629 patients (81.9%) on the lower lid and 72 patients (9.4%) on the upper lid and 82 patients (10.7%) undergoing surgery on both lids. The eyelid was well everted with no recurrence in 740 patients (96.4%). Conclusion. Epiblepharon frequently occurs in Korean children and is correctable with a simple surgery. Recurrence and serious complications do not occur often, and any suspicions of epiblepharon should be investigated. A thorough ocular examination can lead to a correct diagnosis and timely corrective surgery. Most procedures are successful and prevent secondary complications that often occur with uncorrected epiblepharon.

Surgical treatment of severe congenital ptosis in patients younger than two years of age using preserved fascia lata

PURPOSE

To investigate the clinical outcome of a frontalis sling using preserved fascia lata in the treatment of vision-obscuring congenital ptosis in patients less than 2 years of age.

DESIGN

Retrospective, interventional case series.

METHODS

The study was conducted in an institutional setting and included 82 patients with visual axis-obscuring congenital ptosis. All patients underwent frontalis sling surgery with preserved fascia lata between November 1994 and December 2008, and had a minimum follow-up of 6 months. Visual and surgical outcomes were assessed by reviewing clinical photographs and medical charts. Surgical outcomes were defined as good, fair, or poor, based on the postoperative lid level.

RESULTS

The mean age at surgery was 15.3 ± 4.8 months. After a mean follow-up of 54.8 ± 41.4 months, 64 patients (78.0%) showed good or fair surgical outcomes. Reoperation was performed in 16 of the patients with poor or fair results. Amblyopia was treated postoperatively in 75 of the 82 patients (91.5%) and had improved in 65 patients at the last follow-up. Postoperative entropion was identified in 5 cases, all of which were treated successfully. No other significant complications occurred.

CONCLUSIONS

For patients younger than 2 years of age, preserved fascia lata may be an appropriate substitute for autogenous fascia lata in frontalis sling surgery. Its long-term stability may enable a permanent effect in a certain proportion of patients, and may not require secondary surgery, which is common with synthetic materials.

Transconjunctival epiblepharon repair

PURPOSE

To document the use of a transconjunctival approach to lower eyelid epiblepharon repair.

MATERIALS AND METHODS

Retrospective chart review of all patients who underwent transconjunctival lower eyelid epiblepharon repair.

RESULTS

Nine patients underwent repair via this approach. All patients experienced the resolution of their keratitis and cilia-cornea touch by a 3-month postoperative interval, and no patient developed a postoperative complication. Furthermore, no patient developed cutaneous scarring.

CONCLUSIONS

Conventional approaches to lower eyelid epiblepharon repair have necessitated the creation of a skin and muscle flap, thus risking the development of scarring and a cosmetically unacceptable eyelid crease. This report documents the use of a transconjunctival approach for the management of this condition that avoids external incisions and provides excellent outcomes without scarring of the anterior lamella of the eyelid.

Lower eyelid involutional entropion repair with lateral tarsal strip and infraciliary rotation sutures: surgical technique and outcomes

PURPOSE

To describe a novel technique for the surgical repair of involution entropion of the lower eyelid and to evaluate its effectiveness in a series of patients.

METHODS

This retrospective interventional case series includes patients who underwent entropion repair via lateral tarsal strip with infraciliary rotation sutures during a 5-year period by one surgeon. Demographic data was collected and incidence of recurrence was determined.

RESULTS

Forty-four eyelids of 36 patients with involutional entropion underwent surgical repair via lateral tarsal strip plus infraciliary rotation sutures. All patients had successful repair of entropion with no recurrences recorded on follow-up, which ranged from 1 to 67 months.

CONCLUSIONS

Lateral tarsal strip combined with infraciliary rotation sutures is a successful method for the repair of involution entropion of the lower eyelid.

CASE REPORT How to Repair the Lower Eyelid Retraction, Resulting From the Primary Surgery for Epiblepharon?

OBJECTIVE

Among the surgical procedures used to correct the positions of the eyelids or improve their cosmetic appearance, procedures for treating eyelid retraction are some of the most challenging. Lower eyelid retraction can occur iatrogenically after various surgical procedures. We performed a successful corrective procedure for lower eyelid retraction, which had occurred at some point in the 2 decades after primary surgery for epiblepharon.

METHOD

A 23-year-old woman underwent primary surgery for bilateral epiblepharon at the age of 5 years. However, at the age of 17, she noticed that an abnormally large proportion of her right sclera was visible when her eyes were in their natural position. In the primary position of gaze, the distance from the lower limbus of the right cornea to the upper margin of the lower eyelid was approximately 2 mm. An incision was made in the lower eyelid along the scar caused by the previous operation. Subsequently, the connections between the tarsus and the lower eyelid retractors were broken, and harvested auricular cartilage was placed between the lower edge of the tarsus and the lower eyelid retractors.

RESULTS

One year after the operation, there was no gross difference in the distance between the lower margin of the corneal limbus and the lower eyelid on either side, and the patient was extremely happy with the results.

CONCLUSION

Using a novel surgical technique, we successfully lengthened the posterior layer of the lower eyelid retractors with a small amount auricular cartilage, resulting in good functional and cosmetic outcomes.

Surgical correction of epiblepharon using an epicanthal weakening procedure with lash rotating sutures

BACKGROUND

To describe a new surgical technique in patients with lower eyelid epiblepharon using an epicanthal weakening procedure with lash rotating sutures.

METHODS

Charts of patients with epiblepharon who underwent surgical correction using an epicanthal weakening procedure with lash rotating sutures were reviewed retrospectively. The preoperative severity of corneal erosion was graded and compared with the postoperative keratopathy. Postoperative surgical outcomes, complications and subjective satisfaction were also evaluated.

RESULTS

202 eyes of 101 patients were evaluated in this study. The preoperative cilia-corneal touch was corrected and keratopathy was improved, especially towards the medial aspect of the lower lid. There were four eyes (2.0%) of recurrent cilia-corneal touch, but none required reoperation. Cosmetic outcomes were considered to be 'very satisfied' in 95 patients, 'satisfied' in 6 patients, and no patients indicated 'neutral' or 'dissatisfied' results.

CONCLUSIONS

In patients with epiblepharon with an epicanthal fold, surgical correction using an epicanthal weakening procedure with lash rotating sutures is a simple and effective method for correction, particularly when evaluating the medial portion of the lower eyelid. This method also produces a favourable cosmetic outcome with minimal scar formation.

Outcomes of various surgical procedures on acquired lower eyelid epiblepharon in thyroid associated ophthalmopathy

Purpose

To report the outcomes of acquired lower eyelid epiblepharon after various surgeries in thyroid associated ophthalmopathy (TAO) patients.

Methods

A retrospective review of the medical records of 53 TAO patients with acquired lower eyelid epiblepharon between October 1999 and June 2011 was performed. Data were collected on demographics, type of lower eyelid epiblepharon, the detailed surgical history such as orbital decompression, retraction repair, or epiblepharon repair and surgical outcomes including follow-up period, recurrence of epiblepharon, and post-operative complications.

Results

Among the 53 TAO patients with acquired lower eyelid epiblepharon, 25 eyes of 17 patients underwent surgical management; 6 eyes of orbital decompression, 1 eye of orbital decompression followed by retraction repair, 2 eyes of orbital decompression followed by epiblepharon repair, 6 eyes of lower eyelid retraction repair, and 10 eyes of epiblepharon repair. Twenty two lower eyelid epiblepharons (88%) were resolved after final surgical treatment without complication during mean 16.2 months (SD, ±29.9 months) of follow up period; three of 6 epiblepharons that remained after orbital decompression underwent subsequent surgical management of retraction repair or epiblepharon repair, and epiblepharons were well-corrected. Mean amount of lower eyelid retraction was decreased from 1.68 mm (SD, ±1.17 mm) to 0.29 mm (SD, ±0.44 mm) after surgery, regardless of the type of surgery (n = 25, p < 0.000, Wilcoxon signed rank test).

Conclusions

Acquired lower eyelid epiblepharon of TAO should be managed sequentially according to the general serial order of surgical managements in TAO; orbital decompression, correction of lower eyelid retraction and epiblepharon repair. Acquired lower eyelid epiblepharon was well resolved after surgical management in consecutive order, especially after repair of the lower eyelid retraction with a graft, or lower eyelid epiblepharon repair. Decreased lower eyelid retraction with a resolution of epiblepharon after surgery implied that lower eyelid retraction was associated with lower eyelid epiblepharon.